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Information for Upper Limb Amputees And Their Families

The most important goal of your entire treatment from surgery to rehabilitation, to the fitting of your prosthesis is to help you attain the most function and mobility possible, so you can lead an active life.

Your therapy team, which includes your doctors, therapists, prosthetists and of course, you and your loved ones will help you achieve the most independence possible. On average, this rehabilitation process takes between two to six months, although this can be affected by various factors, including your level of motivation and how well your prosthesis fits.

Recommendations with regard to your therapy and rehabilitation are provided below. However, the instructions from your rehabilitation team always take priority since this team is best able to evaluate your individual situation.

Before Amputation

Whether you’ve known about your amputation surgery for a while, or just found out, remember that you’re not alone. Your treatment team is there to support you, answer questions and find the best solutions for you.

If you are to undergo planned amputation surgery, you will be examined in detail several times before the surgery. Your doctors will explain what will happen both during and after the operation. Of course, if you’ve had a traumatic accident, your conversations will occur after the surgery.

During these discussions, you have the opportunity to ask any questions which are important to you. It’s a good idea to take notes of what you want to ask the doctor before the discussions so that you don’t forget anything. Remember that it’s their job to explain it all clearly to you.

If possible, you should begin doing those therapy exercises you’ll use after amputation surgery before your surgery takes place. That way you can strengthen your muscles in advance. It also makes sense to practice moving properly from the bed to the wheelchair as soon as possible. The timely training of such activities can make the time after the operation considerably easier on you. Ask your doctor and your physical therapist which exercises are right for you.

It’s also a good idea to talk to a prosthetist before the amputation about which types of prostheses might be right for you.

An amputation is a big change in your life and it may be helpful to get psychological counseling. Counseling can help you work through any issues or fears you may have, while taking some of the weight off of your friends and family and yourself.

We also recommend that you talk with peers who have also undergone amputation surgery. It is good to hear how others deal with the situation, and in many cases they’ll also be able to share tips on everything from using your prosthesis to getting the right fit. Talk to your therapy team about how best to get in contact with peer support groups.

Amputation

Find out more about what ‘amputation’ means, including types of amputation and possible causes of amputation.

What does ‘amputation’ mean, and why is it done? Amputation is described as the separation of a bone in healthy tissue or the removal of a limb at a joint (exarticulation).

Amputation surgery may be necessary if an injured or diseased limb is not expected to heal and if the patient’s life is endangered as a result. Possible causes include circulation issues, infections, accidents, cancer, or a congenital malformation of the limb. In these cases, it is usually known well in advance that an amputation will become necessary. In contrast, sometimes it is necessary to amputate unexpectedly, for example due to a severe injury after an accident.

What does "Amputation level" mean?

Foot amputation

Over twelve different amputation levels are common in the foot area. They range from a toe amputation to a metatarsal amputation or amputations in the tarsal area.

When there is less need for or difficulty in fitting a prosthesis that offers increased function, Cosmetic silicone prostheses are sometimes used.

Transtibial amputation

For transtibial (also known as ‘Below the Knee’ or ‘BK’) amputations, the amputation occurs through the tibia and fibula bones of the lower leg.

The transtibial prosthesis consists of a socket, which contains the residual limb (the amputated limb, colloquially referred to as the ‘stump’), a prosthetic foot as well as adapters and connecting elements. Information on these products is available here. A prosthesis can be disguised with a cosmetic cover so that it is hardly noticeable visually.

Knee disarticulation

In knee disarticulation surgery the knee joint is separated and the lower leg is removed. The entire thigh is retained in the process.

The prosthesis consists of a socket, which contains the residual limb (the amputated limb, colloquially referred to as the ‘stump’), a prosthetic knee joint, and a prosthetic foot, as well as adapters and connecting elements. Information on these products is available here. A prosthesis can be disguised with a cosmetic cover so that it is hardly noticeable visually.

Transfemoral amputation

In a transfemoral amputation (also known as ‘Above the Knee’, or ‘AK’), the amputation occurs through the femur, or thigh bone, of the upper leg, so that the knee is no longer present.

Hip disarticulation

During a hip disarticulation, the amputation is performed in the hip joint area. With this amputation the pelvis will be used to control the prosthesis later on.

The prosthesis consists of a socket, which contains the pelvic area, a prosthetic hip joint, a prosthetic knee joint, and a prosthetic foot, as well as adapters and connecting elements. Information on these products is available here. A prosthesis can be disguised with a cosmetic cover so that it is hardly noticeable visually.

Hemipelvectomy

In a hemipelvectomy, the entire leg, and part of the pelvis up to the sacrum are amputated. With this amputation the pelvis will be used to control the prosthesis later on.

The prosthesis consists of a specialized socket, which contains the remaining pelvic area, a prosthetic hip joint, a prosthetic knee joint, and a prosthetic foot, as well as adapters and connecting elements. Information on these products is available here. A prosthesis can be disguised with a cosmetic cover so that it is hardly noticeable visually.

After Amputation

Immediately after the operation, the focus will be on your recovery and the healing of your residual limb. Both are important so that you can start rehabilitation soon and be fitted with a prosthesis.

After the amputation your residual limb will be treated with a special wound healing bandage. Your doctor’s main goal here is to quickly heal the wound that was caused by the operation and to prepare your residual limb for your future prosthesis.

The focus during the initial period after the operation is on three treatment goals: You should have little to no pain, your residual limb should be able to bear weight, and you should be able to move your residual limb optimally in all directions.

In order for all of this to succeed, it is important for you to have your doctor or physical therapist show you a few important things right after the operation. This includes correct positioning in bed so that the muscles and the joint adjacent to the residual limb don’t retract or become stiff, as well as regular exercise. These measures allow you to be fit more quickly and easily with a prosthesis so that you can remain mobile and active.

Immediately after the operation you will probably not be able to lie still for longer periods or to turn over in bed by yourself. For this reason, have the nursing staff help you shift position several times a day. This change of position is important, since it allows you to ensure the most pain-free position and helps prevent bedsores. It also helps to prevent flexion contractures a limiting in your range of motion at the hip or knee which could make rehabilitation more difficult.

When you wake up from the anesthesia, your leg will have likely been treated with simple bandages or a plaster cast with a small drainage tube leading out of it. This tube was laid into the wound during the operation so that wound seepage and blood can flow out of the wound, and will be removed from the wound during the healing process.

In most cases the amputation wound closes and forms a scar within the first three to four weeks. But even if the scar looks like it has healed well from the outside and only the color of the scar tissue is changing slightly, complete healing of the scar will take significantly longer. It takes about one and a half years until it has healed completely on the inside as well.

During this period compression therapy and skin care creams are enormously important in helping the scar tissue remain soft and pliable while simultaneously developing the ability to bear weight so that it’s possible to wear the prosthesis.

With the aid of pressure applied to the residual limb over a large surface area, swelling (edema) of the residual limb can be reduced and the residual limb can be formed for the future prosthetic fitting. This compression of the residual limb contributes to being able to do your prosthetic fitting as soon as possible and to making it easier to adjust your prosthesis. In addition, compression aids circulation in the residual limb. This reduces the amount of pain and results in improved healing of the scar.

Various techniques are used for compression therapy: The residual limb may be wrapped with an elastic bandage, or compression socks or a prefabricated silicone liner may be worn.

Compression bandages are applied using a special wrapping technique after the wound bandage or residual limb cast is removed. During the first few days and weeks after the operation, your residual limb will be bandaged by your therapist or by the nursing staff. This somewhat elaborate compression involving elastic bandages can be customized to your individual residual limb amputation level.

The bandage will be removed frequently (initially as often as every half hour) in order to make sure the residual limb was not wrapped too tightly or too loosely. The caregiver will also check to see how the residual limb is developing, whether the edema is getting better, and how the scar is healing. After sufficient healing, the compression bandage may only be worn for several hours at a time, for example also before and after wearing an interim prosthesis.

Later on, your caregivers can show you how to apply the compression bandage yourself. Make sure you have the wrapping process explained to you in detail in order to avoid mistakes which could lead to renewed swelling of the residual limb, or to irritation or injury made by folds in the bandage or wrapping that’s too tight. To avoid injurying your sensitive residual limb, use tape on the bandages instead of metal clips.

It is also important that you clean the bandages thoroughly. Since the bandages absorb sweat, they should be washed daily with a mild detergent or a mild soap. Remove the majority of the water by rolling them up gently in a towel, then lay them out flat to dry. Do not hang the bandages up to dry, as this can affect their elasticity.

You have to wear your compression bandages until your residual limb is fully healed. As soon as everything has healed, you can try sleeping through a night without wearing the bandage, but only after consultation with your doctor, prosthetist, or physical therapist. However, if you experience a lot of swelling in the residual limb the next morning, you should continue with the compression therapy.

Compression socks can also be used instead of bandages. The socks are also elastic and available in various sizes. Custom sizes can also be made if the standard sizes do not fit you. Like elastic bandages, the socks must be washed daily and laid out to dry so that they do not lose their elasticity.

The advantage of residual limb socks is that they are easy to put on and take off. You can use suspenders attached to a hip belt to hold the socks up. Or you can use a pelvic band which is fastened permanently to the sock.

In addition to elastic bandages and residual limb socks, silicone liners offer a further method for achieving compression. Similar to residual limb socks, silicone liners are available in standard sizes as well as customized fabrications. The liner exerts even pressure on your residual limb and forms it properly. In addition, the flexible, skin-friendly silicone can help make the scar soft and pliable.

To put the liner on, it is best to first turn it inside out and then roll it evenly onto your residual limb. Don’t pull it up like a sock, and take special care to ensure that no folds or air pockets form.

Clean your liner daily with a skin-friendly, unscented soap and warm water. If you sweat a lot, you should clean it several times a day and possibly use a disinfectant. Have your prosthetist explain the care of your liner in detail and follow directions in your user’s manual.

Although the nursing staff and the doctors were initially cleaning the wound and changing the bandages, now that you are in the rehabilitation phase you will be caring for your residual limb and your sound leg yourself.

Your therapist will show you how to properly care for your residual limb. In order to prevent the skin from becoming rough and scaly, wash the residual limb with warm water and a mild soap (such as Derma Clean) every morning and evening. Then dry the skin thoroughly or carefully dab it dry and put cream on it. Derma Repair and Derma Prevent, two products from Ottobock, were developed specifically to care for highly stressed skin such as that on a residual limb. The Derma Prevent cream, for example, guards against chafing by covering the skin like a protective film keeping it soft and pliable.

If folds of skin or retracted scars, also known as invaginations, have formed on the residual limb, they must receive particularly intensive care in order to prevent infections. Have your rehabilitation team advise you in this regard. In addition, look out for injuries, pressure sores, and blisters while you care for your residual limb. These must receive medical treatment. A mirror can help you look at the back of your residual limb. Regular massaging and careful stretching of the scar is another important component of residual limb care.

Also note that putting the prosthesis on in the morning right after you wash is often more difficult than usual, since warm water causes the skin on the residual limb to swell.

After the amputation, when the residual limb is not yet able to bear a lot of weight, it’s common to put more weight—and stress—on the sound leg. Work with your care team to find the best ways to keep you sound side healthy.

In order for your body to be well prepared for the next treatment steps and so that you remain mobile, exercises to strengthen the trunk, arm, and leg muscles are highly recommended. Have your physical therapist show you exercises which support your recovery and also train the joints near the amputation location as much as possible. You may also want to practice sitting up in bed and making transfers to a wheelchair.

In some cases, an initial prosthesis may be fit about 10 days after a lower limb amputation. With such an immediate fitting, some weight can be applied to the residual limb early on and the first walking exercises can be started. However, this type of prosthesis is not suited to all amputations. Your doctor, physiotherapist, and prosthetist will decide together if this is an option for you. If such an early fitting is possible for you, you will receive an interim prosthesis, which is designed for initial walking and standing exercises.

Fitting & Rehabilitation

Your treatment team will decide when you can start with intensive rehabilitation based on how your recovery is going. During your rehabilitation process, you’ll be fit with a prosthesis tailored to your specific needs, and supported by a rehabilitation team that could include doctors, physical and occupational therapists, a prosthetist and nursing staff. These professionals are there to support you and to ensure that you are well prepared. During rehabilitation you will learn how to properly care for your residual limb, as well as the rest of your body.

Before you can wear a prosthesis, your residual limb must be healed and have attained the proper shape. This means that all fluids that accumulated due to the operation have been removed through compression therapy and that the residual limb edema has subsided.

Once your residual limb has been properly formed and can bear weight, you may be fitted with an early or interim prosthesis. Then you’ll begin to practice using your prosthetic leg. At first you’ll learn how to put the prosthesis on and take it off as well as take care of it. Later, you’ll learn how to walk with the prosthesis, which is known as gait training.

The goal of rehabilitation training with a physical therapist is to help you gain as much mobility and independence as possible.

Your therapist will help you learn how to use your prosthesis properly. This includes putting the prosthesis on and taking it off, getting up and sitting down, and balance and gait training.

The goal of rehabilitation training with a physical therapist is to help you gain as much mobility and independence as possible.

Your therapist will help you learn how to use your prosthesis properly. This includes putting the prosthesis on and taking it off, getting up and sitting down, and balance and gait training.

Correctly putting your prosthesis on (donning) and taking it off (doffing) by yourself is an important everyday task. Your family or friends may need to help you initially, but the goal is for you to ultimately be able to do this on your own.

There are many different ways to put your prosthesis depending on the type of prosthesis you have and the condition of your residual limb. Your therapist will show you which ones are suitable for you.

You have already learned to care for your residual limb, but your prosthesis must also be cared for and cleaned every day, too. Wipe the inside of the socket with a moist cloth to remove sweat residue and skin particles.

Keeping the contact surface with the skin clean helps to avoid skin irritation. If you wear a liner, please care for it daily according to the user manual.

Informasi mengenai Training

Training: Walking on a level surface

Once you feel secure using your prosthesis, you can begin with the actual walking exercises. You’ll work on improving balance and coordination, transferring sufficient weight to the prosthesis side and about keeping your pelvis and upper body aligned

In addition, you should continue strengthening your muscles, since strong muscles are an important prerequisite for a stable posture while walking.

First you will learn to shift your body weight while using the parallel bars and to stand on one leg. You’ll need to learn to trust your prosthesis, and not to put all your weight on your arms and your sound leg. After you’ve gotten confident walking in the in the parallel bars, you’ll begin to walk in open space. You’ll goal is to reduce your need for walking aids, bit by bit. You can achieve this through a combination of the using the right walking technique and by strengthening your trunk muscles.

It’s important to use proper form while doing the exercise. Your therapist will help you at first, until you’re able to do it on your own.

Training: Walking safely on ramps and stairs

On any given day you’re sure to encounter obstacles, such as curbs, steps in the house, sloped surfaces at garage entrances, and so on. Here, the components in your prosthesis are particularly important since different prosthetic knee joints require different walking techniques. Correct positioning of the foot or the use of the handrail, for example, also play an important role.

Training: Sitting down and standing up

After putting it on and taking it off correctly, sitting down and getting up are the next everyday movements you will learn.

The exercises for this are based on the components which were used in your prosthesis. With an Above Knee (transfemoral) prosthesis using the C-Leg knee joint, for example, it is possible to place weight on both legs while lowering yourself to a seated position. This is a significant factor in reducing strain on the sound side, helping to reduce overuse.

For the same reason, you should place weight equally on both legs while sitting down and getting up with a transtibial (below knee) prosthesis.